Patient Resources

Structural Empowerment

Clinical nurses have a voice within the UT Southwestern shared governance organizational structure, which is built on a solid foundation of teamwork and collaboration. Shared decision-making and accountability empower nurses with a process for determining professional nursing practice. These organizational standards are developed through staff-led interdisciplinary committees, task forces, and councils to improve patient outcomes and experiences. Nurses at all levels take conscious ownership of patient care, safety, ethics, research, performance improvement, and evidence-based practice. Our shared governance structure supports the practicing nurse as a key decision-maker with a credible, sought-after perspective. This model strengthens practice by supporting relationships and partnerships among clinical areas, providing an innovative and collaborative environment to bolster our quality patient outcomes.

Shared governance structure

UTSW Shared Governance Structure

UTSW has a strong shared governance structure that includes all staff from all areas and disciplines, as reflected in the accompanying diagram.

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UT Southwestern nurses validate their mastery of skills, knowledge, and abilities through certification and meet ongoing learning and practice requirements through recertification. The process assures patients and their families that the nurse caring for them has demonstrated experience, knowledge, and skill in the complex specialty of their care. Nurse certification and continuing education contribute to an environment of professionalism and a culture of retention. Certification also differentiates UT Southwestern from other health care organizations, demonstrating to consumers that we have attracted the most skilled and experienced nursing professionals. By the end of FY 2022, UTSW employed 2,103 specialty certified nurses.

Educational Levels

A significant body of research indicates that a more highly educated nursing workforce can help ensure the U.S. population has access to high-quality, patient-centered care. The Institute of Medicine (IOM) recommends having at least 80% of nurses holding a bachelor’s degree or higher. The UT Southwestern Nurse Executive Board (NEB) Cabinet has been working to increase reimbursements for nurses pursuing higher degrees to encourage their educational efforts while still working. The UTSW Nurse Executive Board is ultimately responsible for putting in place programs and policies promoting higher education for nurses in all areas. As illustrated in the graph on the right, our program has steadily maintained the objective of having at least 80% of our nurses hold a B.S.N., at a minimum.

Total number of RNs with B.S.N. or higher = 2,554

Clinical Ladder

UT Southwestern’s Clinical Ladder process promotes clinical growth, professional growth, and development; addresses recruitment and retention; and encourages and rewards nurses in direct patient care and nonadministrative roles.

“Recognition, reward, and retention of the experienced nurse in positions of direct clinical practice – along with the documentation and adequate description of their practice – are the first steps in improving the quality of patient care.” (Patricia Benner, M.S., RN, “From Novice to Expert.” American Journal of Nursing, 82(3), 1982, p. 407.)

The UTSW Clinical Ladder is open to all clinical nurses involved in direct patient care.

2022 Inpatient Nurse, Ambulatory Nurse, and APP Clinical Ladder Achievements Graphs

Education Outcomes

Clinical Education and Professional Development (CEPD) and the Department of Ambulatory Clinical Education and Professional Development both support nursing and therapy staff members across inpatient and ambulatory areas, advancing the philosophy, mission, and vision of UTSW Nursing Services. In 2022, a group of dedicated educators committed to excellence in education put into place the Nursing Professional Development Practice Model (ANPD, 2016) to leverage learning to meet and exceed organizational outcomes.

UT Southwestern Nursing Professional Development (NPD) practitioners are master’s-degree-level prepared in nursing education and require NPD certification within 18 months of hire. NPD practitioners operationalize environmental scanning, proactively plan educational programming, and work collaboratively with unit-based educators and clinical educators on both teams to meet the learning needs at the individual, unit, and organization level. Unit-based educators and ambulatory clinical educators are registered nurses with a minimum of a bachelor’s degree plus clinical expertise specific to the units and clinics they support.

Professional Development

UT Southwestern is an accredited provider of Nursing Continuing Professional Development (NCPD) by the American Nurses Credentialing Center’s (ANCC’s) Commission on Accreditation. Prior to 2021, nursing leadership hired an inpatient Accredited Provider Program Director and initiated Nurse Planner orientation for 10 NPD practitioners and five advanced practice providers. Through calendar years 2021 and 2022, more than 280 NCPD activities were offered with an overall total of 1,769.43 contact hours; 2,243 nurses sought NCPD credit, and 45 enduring sessions were offered. Activity highlights included Nursing Grand Rounds, Ethics in Science and Medicine Grand Rounds, Celebration of Excellence, Rapid Improvement Event (RIE) training, Year of the Nurse, and a Summer Fellowship in Quality Improvement and Patient Safety.

Aspire to Achieve seminars support nurse leadership training, focusing on the needs of the clinical leader at both bedside and in the clinic. All current nurse supervisor coordinators, assistant nurse managers, nurse managers, and nurse directors attend this educational series, led by the Advisory Board and Organizational Development and Training, alongside nurse leaders.

NCharge classes focused on fundamentals of the charge nurse role, supervisory skills, and leading change for more than 400 frontline nursing leaders.

Ambulatory Residencies and Student Placements

  • MOA residents: 8 residents in 2 cohorts
  • Ambulatory RN residents: 8 RN residents
  • Nursing students placed in clinics: 97
  • MOA externs: 21

Clinical Education

In 2022, our education teams facilitated more than 128,000 online lesson completions in 650+ unique courses for clinical staff across the health system in both the hospital and ambulatory settings. Top courses included Crash Cart Updates, COVID Training for RNs, RN Onboarding, Central Line Dressings, COVID Medication and Vaccine Safety, and Essentials of Critical Care Orientation for Nurse Residents/RN Fellows.

Nursing student placements exceeded 700 from nine affiliated Schools of Nursing, with 20 summer externs.

Resuscitation Quality Improvement (RQI) Program

The UT Southwestern Resuscitation Quality Improvement (RQI) program is an authorized American Heart Association training center providing Heartsaver, BLS, and ACLS courses to UT Southwestern employees and students. In 2022, we continued expanding our off-site clinic and additional locations so clinical staff across the UTSW system were able to participate in the RQI program. The program now serves more than 5,600 staff members with hands-on skills training each quarter within their clinical area, along with onsite classroom BLS, ACLS, and Heartsaver courses, serving more than 1,000 additional staff.

RQI Program


  • Advanced practice providers have been added to RQI HeartCode 800-850
  • Ambulatory satellite clinics in Frisco, Las Colinas, the Park Cities, and Richardson use portable station to complete renewal
  • UT Southwestern Medical Center at RedBird added an RQI station

Instructor-Led Classes

  • BLS Participants: 400-450
  • ACLS Participants: 250-300

NRP Neonatal Resuscitation Improvement Program

The Neonatal Resuscitation Program facilitated a total of 23 classes, including classes for the nurse residents and fellows. The NRP program has fully transitioned to the RQI platform. In 2022, a total of 146 participants completed NRP classes including 17 residents and fellows. This is the 2022 course and participant breakdown below:

  • NRP Essentials – 10 classes, 87 participants
  • NRP Advanced – 10 classes, 42 participants
  • NRP for Residents – 3 classes, 17 residents

Transition to Practice

CEPD continues to lead three practice transition programs. The UTSW Nurse Residency Program is accredited by the American Nurses Credentialing Center (ANCC) Practice Transition Accreditation Program. In 2022, the program’s ambulatory track added more graduates. In addition, our Patient Care Technician (PCT) Residency Program partners with Dallas College under the “You’re Hired” grant from the U.S. Department of Labor to expand apprenticeship programs. Throughout 2022, more than 300 nurses and PCTs were hired into the practice transition programs, including:

  • 277 nurse residents
  • 63 RN fellows
  • 33 PCT residents
  • 8 MOA residents

Achieving 100% Flu Vaccination Policy Compliance Before End of Year

Ensuring compliance for the Health System Influenza Vaccination policy proved to be a challenging task for Occupational Health Services. To be considered compliant, each employee must be vaccinated by Occupational Health, provide proof of being vaccinated, or submit documented declination of vaccination by November 15 of each year. In the 2021-2022 flu vaccination season, the compliance rate was 88% by December 2021. A new strategy was implemented to help nurses in Occupational Health reach 100% compliance the following year.

Beginning in summer 2022, Employee Relations and Occupational Health Services met regularly to develop an action plan to improve the rates. In addition to early and frequent communications about the vaccination period, marketing plan barriers were identified and removed. As barriers were identified, a strategy was implemented using automated individualized emails to managers, directors, and AVPs. The emails included individualized links to reports identifying to managers their noncompliant staff members. As time progressed, noncompliant reports were generated weekly for Employee Relations and daily for leaders. By December 2022, 100% compliance was achieved for non-faculty employees.

Improving Patient Discharge Times on 10 Blue

Patients needing to be discharged after a lung transplant procedure require a complex coordination of a multidisciplinary care team. Data collected on the lung transplant recipient discharge process revealed there might be some delays in the process that could be improved. A task force was created to perform a gap analysis and evaluate reasons for delays. The team was also responsible for designing strategies to meet earlier discharges.

During the study period from October 2020 to August 2022, 933 lung transplant recipients were discharged from the hospital. The data collected came from three categories: discharge order time (DOT), actual time of discharge (ADT), and reasons for discharge delay. Frequent barriers for delay of discharge included transportation, medication delivery, laboratory work, and placement of discharge orders by the provider team. Interventions for improvement included priority discharge rounding, collaborative communication with care coordination, and beginning patient education at the time of admission; all were implemented as strategies. At the beginning of the study period, the mean discharge order time and actual discharge time was between 13:10 and 15:17. As of September 2022, the mean DOT and ADT remained at between 12:49 and 15:16.

Residency Program Aims to Set Up Medical Office Assistants for Success in Ambulatory Clinics

Certified medical office assistants (CMOAs) contribute significantly to the success of any clinical setting. When these roles are left vacant, clinicians are left to pick up additional tasks, and, on occasion, it can make the visit for patients longer if the clinic is short staffed. Because ambulatory clinics at UT Southwestern are growing, the need to increase CMOA staffing became a clear goal for leadership. Across more than 90 ambulatory clinics, management needed to fill 75 open CMOA positions. A grant was secured to create a UTSW CMOA residency program in partnership with Dallas College.

The residency became a 12-month training program that included 12 weeks of classroom education, a certification exam, and 2,000 clinical hours at UTSW. The program was developed to include two cohorts of five residents every calendar year. After residents completed classroom requirements, they were paired with a preceptor in their designated clinic to help guide their transition to becoming independent. Since the first cohort in February 2022, three of the first five residents completed the program and have transitioned to their desired clinic. The number of interested clinics willing to host residents has also increased from three to 11.

Aligning Long-Term Pathway Goals with Patient Progression Timelines

Intervention Start Date Graph

Nurses on Zale 5 are striving to become part of a Spine Center of Excellence. As part of the process to reach that goal, multidisciplinary rounds (MDRs) were initiated to identify areas of opportunity and to integrate pathway discussions and evidence-based practice recommendations. Caring for the spine patient population allowed for seamless alignment of the clinical pathway outcome to the Enhanced Recovery After Surgery (ERAS) guidelines. The goal was set to improve the length of stay for patients by ensuring best possible outcomes and predicted discharge dates.

The combination of interventions to decrease the length of stay included the implementation of ERAS guidelines built into Epic, MDRs, and the use of whiteboards. Whiteboards served as a better communication tool for the teams and patients because they were used to update daily progression, disposition, and discharge dates for patients. Demonstrating the discharge date on the whiteboards also prepared the patient, creating less anxiety related to discharge. The unit has continued to maintain the length of stay in the 0.80s for the past three months.

Building Trust with Geriatric Patient Populations by Boosting Responsiveness

The program has improved responsiveness performance measurements of “help toileting as soon as you wanted” at 85.62% and 99% ranking.

Nurses on 12 Blue identified responsiveness to patients' needs as a top priority for their unit. Helping geriatric patients get to the toilet as soon as they want was one way the team could improve this operational goal. After consulting with UTSW geriatricians, nurses found existing literature addressing falls related to toileting but no information addressing the quality aspect of the patient’s perception of responsiveness. The unit addressed this issue in part by having nurses use the Hester Davis fall risk assessment to score patients on urgency. Those who scored as having urgency were enrolled in a scheduled toileting program where the patients were taken to the bathroom every hour.

Nurses used a teamwork approach in getting their patients to participate in the toileting program. Early in the project, a challenge was issued to use the chat function (in Epic) to engage all team members because it is probable that both the primary nurse and the patient care technician (PCT) are in different rooms at the same time. The charge nurse had an Epic report of patients with this risk factor; they notified the health unit coordinator (HUC) so that person could give the hourly toileting form to the oncoming RN. The primary RN coordinated with the PCT to toilet with the patient at the top of the hour. The team used clear and supportive communication with the patient, such as, “I am here for your hourly rounding. Let’s go to the bathroom; I have the time.” Caretakers were encouraged to stay in the room and provide moral support. If the patient continued to decline toileting, nurses encouraged the patient to attempt double voiding to see if that would help with emptying the bladder.

Finding a Sense of Belonging in the Advanced Practice Provider Group

More than 900 people in UT Southwestern’s advanced practice provider (APP) group provide expansive care across all campuses in the UTSW Health System. Starting a job in such a complex and geographically vast system, it can be hard on new hires to feel a sense of belonging. The Glint survey and a wellness needs assessment reported that UTSW APPs had a lower sense of belonging than the national benchmark. The APP Engagement Committee was formed in 2020 to empower APPs in collaboration with our existing Wellness and Recognition committees. A secondary subcommittee, the Resources and Connections work group, formed to fill a different need; APPs wanted to get to know their peers.

Coffee Chats became the centerpiece of the newly formed Resources and Connections work group. To help foster a sense of belonging, the initial target group included APPs who were in their first six months of tenure. The chats covered introductions, spotlights on APP centered events, and other opportunities for engagement. Committee members successfully rotated dates and times to ensure APPs working nights could also attend if they wanted. The chats quickly expanded to include APPs hired within the prior year. Coffee Chat participants were asked to give feedback on their experience to help guide future conversations and address the needs of APPs within their own first 12 months of hire. The impact of the chats allowed new APPs to build a social network and connections outside of their own clinical and geographic work area. The experience of Coffee Chats was rated as very good to excellent by 88.9% of participants.

Creating a Multidisciplinary Approach to OR Configurations on L&D

The workflow for the OB anesthesia team is critical to the success of the Labor & Delivery services on 5 Blue. In 2021, the operating rooms on the floor were adjusted to improve the needs of the anesthesia team as the sole focus of the new OR configuration. As time passed, circulating nurses, surgeons, and OB surgical technicians spoke up about how the configuration was not working for all. Some of the issues identified included increased risk of cross contamination, difficulty in accessing needed supplies, patient privacy concerns, and increased difficulty getting the patient on the OR bed emergently. An OR Reconfiguration Task Force was organized to meet the needs of all key stakeholders and produce a multidisciplinary approach to make adjustments.

The task force met weekly for months and approached the reconfiguration with small adjustments based on the feedback from each discipline. Adjustments included reorientation of the OR bed to allow the back table to be farther out of traffic, decluttering the OR, utilizing case carts to be in alignment with the main OR, utilization of suture trees, and removing items to declutter the workspace.

The Director of Surgical Services provided expert consultation to ensure ideas and suggestions met AORN standards and how best to utilize the OR space. Once the reconfiguration was complete, caretakers reported positive feedback with the improvements, which included adequate spacing for L&D nurses and NICU staff. L&D and certified surgical technicians reported improved ability to protect the sterile areas, and patient privacy became easier to maintain. Prior to the reconfiguration, the OR configuration was mentioned in several debriefs by multiple disciplines as a barrier to care. Since the reconfiguration, there have been no negative issues brought up during debriefs, and staff report a great improvement in workspace flow.

Improving Crisis Call Care Coordination from Access Center to Psych Clinic

The Access Center provides centralized scheduling support for numerous ambulatory clinics, including the Psychiatry Clinic. The center can also receive inbound calls from patients with clinical questions or concerns. The Access Center and the clinic have established protocols to ensure appropriate management of calls based on urgency. Despite these protocols, both nurses and call center agents reported various challenges in coordinating care for patients in crisis. Patient Safety officers also received several safety events concerning delays and lack of effective coordination. To tackle this problem, the project team conducted a Failure Modes and Effects Analysis (FMEA).

Using FMEA methodology, a risk priority number (RPN) for each possible failure in the process, based on severity of harm, frequency of occurrence, and detection ability was used to prioritize the risks and focus the action plan. The action plan consisted of three main goals: (1) improve the handoff turnaround from the Access Center to the Psychiatry nurse, (2) improve the accuracy of crisis referrals from the Access Center to the Psychiatry nurse, and (3) develop and roll out a comprehensive training curriculum for all teams within the Access Center. Subsequent improvement was evident in the turnaround time and in the accuracy of referrals, but more time was needed to see the results stabilize. The comprehensive training curriculum was also rolled out successfully. A downstream effect was the decrease in the use of “high priority” encounters, which resulted in more effective use of nursing resources.